Matilda sat in the hall near X-ray holding up a wrinkled little hand. Tiny and looking every one of her 88 years, the woman was still with it. She had taken three busses and walked blocks to get to my office — all by herself. And despite her broken English she was making herself very clear.
“She’s a lock and a hurt and a sleep all the time,” was the answer to “What’s wrong with your hand?” as I bent over to take a look. Mattie had simultaneous and rather bad cases of two hand-surgical classics, carpal tunnel and trigger finger. Other docs had given splints and shots, but she was still getting worse. It was apparent that if someone didn’t release the pressure on that nerve in her wrist soon she would never get better — the nerve damage would become permanent. The other problem, triggering, was bad too. It made opening her hand painful and difficult. My new patient needed two small operations, about 15 minutes of actual surgery, to cure these problems forever.
The daunting task of explaining the problems and operations was easier than I expected — a little deaf but she was a sharp cookie. She got the picture.
“So when you fixa my hand?”
“Just talk to my secretary and she’ll make our appointment for the operation at the hospital.” I gave her the name of the nearest one — where I’m on staff.
“Oh doct, I no canna go there, it’sa too much money.” She opened her purse, whipped out an envelope, producing a letter from Blue Cross and pushed it across my desk. It was the kind of long insurance company letter that instantly makes my eyes glaze over. “Oh don’t worry, Mattie, you have insurance, you will only have a co-pay — maybe fifty dollars.” With age-dimmed eyes she scanned the page and jumped up. Pointing with her crooked, numb finger, she put the letter in front of my face. “Right here — they don’t pay if I go to that hospital — why canna you fix it ina you office doct?”
Well, I looked and she was right. Though they hadn’t told us surgeons yet, the community hospital where I’ve worked for twenty years finally did what so many of us in medicine have been thinking about doing for so long; they responded to yet another rate decrease by saying “no” — we won’t accept it — we can’t afford to pay our nurses, buy the medicines and give the personal attention we want for each patient at those rates. ‘Good for them’ I thought. But then I looked at Mattie, and my day list of patients — many with the same kind of insurance.
What to do with this patient? How could I even get her to my other hospital, so much farther away? And how am I supposed to take care of all the others? There is no answer; we wait on negotiations between the insurer and the hospital. I twisted some arms for Mattie and got her in, but odds are it won’t work for the next case like hers.
When patients choose a health plan, they typically check the panel of doctors they pay for. Few realize they need to check what hospitals and diagnostic facilities they cover too. And even if they do, that list can change at any time. The unfairness of this bait and switch — to patients and doctors — is pretty nasty. The facilities they sign up for can be replaced by facilities that are, you guessed it, cheaper! Don’t guess they will be better.
A peppery little old lady alerted me to the present danger of a problem that we’ve watched fester for years but never thought would actually hit us. While letting insurance companies “bargain” for them, some basic services have been priced right out of the market.
While premiums, and the CEO’s bonus, have gone up, the dollar value of what people get for that premium, what that insurance pays the hospital or doctor for their services, has gone down.
They order the salmon, the waiter brings fishsticks. But people keep coming back to this restaurant, buying that insurance year after year. The main reason, the insurance industry’s ace up its sleeve is this: people usually aren’t sick — so they don’t care. As doctors we should perhaps be encouraging people to know what they’re buying with that insurance premium, before they become patients.
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